Provider Demographics
NPI:1205201670
Name:FERNANDES, MARY (MSED)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:FERNANDES
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 MOUNT EDEN PKWY
Mailing Address - Street 2:2F
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7838
Mailing Address - Country:US
Mailing Address - Phone:646-479-2205
Mailing Address - Fax:
Practice Address - Street 1:241 MOUNT EDEN PKWY
Practice Address - Street 2:2F
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7838
Practice Address - Country:US
Practice Address - Phone:646-479-2205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY584972174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist